Healthcare Provider Details

I. General information

NPI: 1568868149
Provider Name (Legal Business Name): BRIAN TUAN LUONG D.M.D., M.B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 S MAIN ST
SANTA ANA CA
92701-5717
US

IV. Provider business mailing address

9702 SHANNON AVE
GARDEN GROVE CA
92841-2652
US

V. Phone/Fax

Practice location:
  • Phone: 714-647-0797
  • Fax:
Mailing address:
  • Phone: 714-366-2032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number126
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number126
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number126
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number63276
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: